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Advanced Neurology POTS with tics versus tic-like behaviors

phenomenology of tics, family history of tic disorder, likely to be influenced by popular culture or social
psychiatric comorbidities, and treatment interventions. interactions.
For the purpose of the present study, we systematically
screened the medical records of the two groups of patients 3.2. Case 1
to determine the prevalence of POTS as a comorbidity in A 21-year-old female was referred to the specialist GTS
each group. Clinic for the assessment of her complex motor and
We excluded from the study 56 patients with GTS verbal manifestations, in the form of severe and disabling
(neurodevelopmental tics) who subsequently developed repetitive movements and vocalizations. In addition
a functional overlay (comorbid functional tics), as the to fluctuating neck jerks and other sudden movements
clinical characteristics of this subgroup of patients appear involving her shoulders and arms, she reported self-hitting,
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to differ from those of patients with GTS only. All patients hand clapping and flailing movements. Her complex
provided informed consent and the study was approved by vocalizations included humming, singing, swearing, and
the local section of the National Research Ethics Service. entire phrases (including “I’m faking it”), occasionally
Anonymized data were stored on Microsoft Excel 2019. disrupting intended communication. She attended her
consultation in a wheelchair. She reported the acute onset
3. Results of her tic-like behaviors following a COVID-19 infection
two years before her specialist assessment. In addition to
3.1. Prevalence of POTS her diagnosis of POTS, she reported a longstanding history
None of the 638 eligible patients with GTS had a diagnosis of neurodevelopmental conditions. She was diagnosed
of POTS in addition to neurodevelopmental tics. In the with both high functioning ASD and ADHD, for which
group of patients who developed functional tics since she was prescribed a central nervous system stimulant.
the COVID-19 outbreak, 4/177 (2.3%) had received a Her other pharmacotherapy targeted her longstanding
diagnosis of POTS. A summary of the demographic and anxiety, depression, and insomnia, as well as behavioral
clinical characteristics of the four patients with functional manifestations linked to her previous diagnosis of
tics and comorbid POTS is shown in Table 1. borderline personality disorder. There was a family history
of neurodevelopmental conditions, but no confirmed
The four patients with functional tics and comorbid cases of tic disorders. On neurological examination, there
POTS fulfilled the ESSTS criteria supporting the diagnosis was evidence of highly intermittent and distractible jerks,
of functional tic-like behaviors. Specifically, each patient mainly affecting her neck and arms, as well as complex
fulfilled all three major criteria plus at least one minor vocalizations, including random words and short sentences.
criterion (Table 2). There were no consistent premonitory urges.
Neuropsychiatric comorbidities were common,
including other functional neurological symptoms in 3.3. Case 2
two out of the four patients. Of note, none of them A 17-year-old female acutely developed her first tic-like
developed functional tic-like behaviors that were behaviors after experiencing an increase in her anxiety

Table 1. Summary of the demographic and clinical characteristics of patients (n=4) with functional tics and comorbid POTS
Cases Gender Age at Age at Type of Trigger Family Comorbidities Treatment
assessment tic onset onset (s) history
(years) of tics
Case 1 Female 21 19 Acute Stress, No ADHD, ASD, anxiety, depression, AA, SSRI, BZ,
infection insomnia, EUPD lisdexamfetamine
Case 2 Female 17 15 Acute Stress No NEAD, ASD, anxiety, insomnia, AA, SSRI, mirtazapine,
eating disorder antihistamine, psychotherapy
Case 3 Female 21 18 Acute Nil Yes ASD, anxiety, depression, eating AA, TCA, SNRI, BZ,
disorder, EUPD, Ehlers-Danlos gabapentin, antihistamine,
syndrome psychotherapy
Case 4 Female 24 23 Acute Stress No NEAD, functional weakness, Psychotherapy
functional dystonia, ASD, DCD
Abbreviations: AA: Atypical antipsychotic; ASD: Autism spectrum disorder (high functioning); BZ: Benzodiazepine; DCD: Developmental
coordination disorder; EUPD: Emotionally unstable personality disorder; NEAD: Non-epileptic attack disorder; POTS: Postural orthostatic tachycardia
syndrome; SNRI: Serotonin-noradrenaline reuptake inhibitor; SSRI: Selective serotonin reuptake inhibitor; TCA: Tricyclic antidepressant.

Volume 4 Issue 2 (2025) 104 doi: 10.36922/an.8525